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How long did it take before you knew your insurance coverage?
#1
It's been three months since my first sleep test and I still haven't gotten a firm answer from my insurance company as to what they will cover. So far, I think I've paid less than $150 total, which was mainly co-payments for office visits.

Every couple weeks I'll get a detailed list of all the things being billed to them, and the statement (which they stress "is not a bill") seems to hint that some are being covered while others are in the column which says "we're not sure how much of this we're going to cover yet."

Is this normal? I'm assuming that the delay is because of negotiations between the sleep clinic and my insurance company (Aetna) over how much coverage is allowed but this seems a bit ridiculous.

For the record, I had a sleep test, one follow up visit, then a titration, followed 3 weeks later with another follow up visit, plus my CPAP machine and related hoses and masks. I was referred to them by my doctor, so they are a "preferred provider."
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#2
being referred by your doctor does not make them a preferred provider. Aetna has a website that tells who their preferred providers are... I no longer have Aetna so do not have a login, but I know that information is there. Your plan should also tell what coverage you have for Durable Medical Equipment and what your copays are.

try here:
http://www.aetna.com/dse/search?cid=ppc-...na&s_dfa=1



That said, they should be getting back to you with answers. If you dont get them, and it is employer provided insurance, your HR department can get you what you need. If it is individual coverage, a letter to the states insurance commissioner may be in order.
هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
Tongue Suck Technique for prevention of mouth breathing:
  • Place your tongue behind your front teeth on the roof of your mouth
  • let your tongue fill the space between the upper molars
  • gently suck to form a light vacuum
Practising during the day can help you to keep it at night

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
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#3
novatom,
In my experience, a sleep clinic won't normally schedule you for a sleep study until they have had prior approval from your insurance. It's all about money!
You might want to contact your insurance and ask for a statement to see what they covered.
I have a feeling you would have received a bill by now.
Good luck
OpalRose
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#4
(02-27-2015, 02:09 PM)novatom Wrote: It's been three months since my first sleep test and I still haven't gotten a firm answer from my insurance company as to what they will cover. So far, I think I've paid less than $150 total, which was mainly co-payments for office visits.

Every couple weeks I'll get a detailed list of all the things being billed to them, and the statement (which they stress "is not a bill") seems to hint that some are being covered while others are in the column which says "we're not sure how much of this we're going to cover yet."

Is this normal? I'm assuming that the delay is because of negotiations between the sleep clinic and my insurance company (Aetna) over how much coverage is allowed but this seems a bit ridiculous.

For the record, I had a sleep test, one follow up visit, then a titration, followed 3 weeks later with another follow up visit, plus my CPAP machine and related hoses and masks. I was referred to them by my doctor, so they are a "preferred provider."


Get your prescription. Then go to an in-network DME and get the prescription fulfilled. Someone is dropping the ball here, and it's going to have to be up to you to pick it up and run with it. Tell your doctor you need your prescription now. There should be no excuses like we need more study or anything...if that comes up demand an Auto titrating machine prescription and get on with your life.
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#5
(02-27-2015, 08:42 PM)Sleeprider Wrote:
(02-27-2015, 02:09 PM)novatom Wrote: It's been three months since my first sleep test and I still haven't gotten a firm answer from my insurance company as to what they will cover. So far, I think I've paid less than $150 total, which was mainly co-payments for office visits.

Every couple weeks I'll get a detailed list of all the things being billed to them, and the statement (which they stress "is not a bill") seems to hint that some are being covered while others are in the column which says "we're not sure how much of this we're going to cover yet."

Is this normal? I'm assuming that the delay is because of negotiations between the sleep clinic and my insurance company (Aetna) over how much coverage is allowed but this seems a bit ridiculous.

For the record, I had a sleep test, one follow up visit, then a titration, followed 3 weeks later with another follow up visit, plus my CPAP machine and related hoses and masks. I was referred to them by my doctor, so they are a "preferred provider."


Get your prescription. Then go to an in-network DME and get the prescription fulfilled. Someone is dropping the ball here, and it's going to have to be up to you to pick it up and run with it. Tell your doctor you need your prescription now. There should be no excuses like we need more study or anything...if that comes up demand an Auto titrating machine prescription and get on with your life.

sounds like he already has a machine/mask, etc. and is wondering about his insurance coverage I think he may need to update his profile to reflect that
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#6
I got the answers yesterday and feel a bit stupid that I didn't do my due diligence ahead of time. Bottom line: My sleep clinic is not "in-network" but the doctor who works there is in-network. The doctor is a contractor however so when the sleep clinic billed the insurance company for the equipment, they used the wrong ID number and the coverage was rejected. They're in the process of "fixing it," but for a brief moment yesterday, I thought I was going to be responsible for more than $2000 in expenses. The sleep test and titration were all covered and have been paid for, but the equipment was not, but both the clinic and the insurance company assured me that the equipment would be covered by my insurance under my the Doctor's in network status. I know I'm out of $500 already to meet my deductible, I was prepared for that, but $815 a month for renting the machine?! I was appalled at the amount they're billing the insurance company! As long as it's covered, it's OK by me, but such an outrageous amount, when I could buy one online for less than 2 months rent!

That is weird though, that the Dr. can be in-network, but the clinic is not in network, and yet the tests and equipment are still covered. I've been fortunate in that I rarely have to deal with expensive medical procedures (my last was a colonoscopy a couple years ago), so I'm not used to having to investigate and do my "due diligence" on insurance coverage. I went into this sorta "riding blind" and made a lot of assumptions that I won't do again.
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#7
@novatom -

Quote: I went into this sorta "riding blind" and made a lot of assumptions that I won't do again.

But, most of us were at a distinct disadvantage in our sleep-deprived state. you shouldn't be too hard on yourself.

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#8
Novacom,

Hang in there. Having the wrong code submitted and denied is a very common occurrence, especially when first starting a treatment plan. I get it all the time. The facility that charged you simply resubmits with the proper code.

Network vs non-network depends on the insurance. With my insurance, the difference only means how much I am responsible. It is very common for doctors in the same practice to have different network status. And, it is very common for a network doctor to use a non-network facility. Remember, they are dealing with multiple insurers whereas you and I usually only one or two at a time.

Hope this answered some of your questions.

Homer
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#9
Anyone who has dealt with Insurance understands that the experience can be trying and painful at times. I first met with my PCP in November to discuss having a new sleep study done. It is important that along the way, you work through the process with your PCP, Sleep Center, DME and Insurance. I had to have two studies done, I was trying to get everything done by the end of last year, but the process took more time than expected.

Here's some things I learned:
If you get a referral from your PCP for a Sleep Study, call your insurance to check to see that the Sleep Center is in-network. If not, you are going to have an uphill battle.

Ask the Sleep Center which DME they work with? Some Centers push patients to specific providers, who may or may not be in-network for your Insurance.

Check out the proposed DME, look them up on BBB, do they have a supply program - where they ship you CPAP supplies on a 90 day cycle. The better ones do.

When you get the Sleep Study done, ask for a follow-up appointment with the Pulmonary MD. You should tell your Pumonary MD any other medical issues you have, Obesity, Hypertension, Heart Issues like AFib, Diabetes. These all need to go into the report that they write. You should get a Prescription that should have the type of Machine: CPAP/BiPAP and type of mask: Nasal Pillow, Nasal Mask, Full Face Mask, and your pressure setting. Make sure they don't put specific model/manufacturer on the prescription, this leaves you more flexibility in picking the equipment. You should get a copy of the Sleep Study and the Report from the MD. The report needs to have the correct codes.

Choose a DME, for some the choice may be limited to in-network providers. I use an out-of-network DME. I am not going to say why other than we have an arrangement that benefits us both. Some DME push certain equipment. Do some research, read the equipment reviews here. There's plenty of good information to help you choose. Most DME can order equipment that they don't normally carry.

I had a second BiPAP study done in mid-January. It took almost another month to get all the paperwork from the Sleep Center to the DME in a format they requested. It took a long time for the Sleep Center to post all my claims to my insurance. It took about a week and a half to get paperwork straightened out between my DME and Sleep Center. It seemed to be more painful that it should have been. Get the name of the contact with your DME, and talk to them weekly about the status. They are working on multiple patients at one time, and the squeaky wheel get attention. Don't be an a-hole, they are doing their job. Glacier speed it seems at times Smile

Be patient, be persistent, be respectful...

Regards,
Lux
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#10
(02-28-2015, 11:04 AM)Homerec130 Wrote: Novacom,

Hang in there. Having the wrong code submitted and denied is a very common occurrence, especially when first starting a treatment plan. I get it all the time. The facility that charged you simply resubmits with the proper code.

Network vs non-network depends on the insurance. With my insurance, the difference only means how much I am responsible. It is very common for doctors in the same practice to have different network status. And, it is very common for a network doctor to use a non-network facility. Remember, they are dealing with multiple insurers whereas you and I usually only one or two at a time.

Hope this answered some of your questions.

Homer

Thanks, yes I've had this experience before with my insurance company. But insurance or not, it's all still worth it to me.

I still don't understand why the monthly rental fees have to be so high. Huh I hate to think that pricing schemes like this, in some small way, affect my premiums.
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